Mens Health

Anatomy
What lymphatic systems services the testis?
o The right and left lateral para-aortic lymph nodes. (in the abdomen)
Which part of the male genital is serviced by superficial inguinal lymph nodes?
o The scrotum, perineum and the integument of the penis.
What reflexes involve the testicles?
o The cremasteric reflex contraction of the cremaster muscle, in response to
the stroking of the thigh, which results in retraction of the testicle.
Label and describe the anatomy of the scrotum (see figure)
a) Testicular artery
b) Pampiniform plexus. a network of many small veins from the back of the
testis and the epididymidis
c) Head of the epididymidis
d) Efferent ductules
e) Rete testis. An anastomosing network of tubules that carry sperm from the seminiferous tubules to the
efferent ducts.
f) Body of epididymidis
g) Vas deferens. Carrys sperm to ureter a)
h) Tail of epididymidis
i) Tunica vaginalis. This has a parietal and visceral layer b)
i)
j) Tunica albuginea. Projections form septum of lobules,
forms posterior wall of tunica vaginalis.
k) Lobe / seminiferous tubules c)
l) Septum
d)
m) Cavity of tunica vaginalis
j)
What is processus vaginalis?
o An out pouching of the parietal peritoneum that k)
descends with the testis to form the Tunica vaginalis. e)
If it does not fuse properly there is a propensity for an l)
f)
indirect inguinal hernia or congenital hydrocele to
develop.
Wat muscle controls the location of the testis? g)
o The dartos muscle, located inside of scotum. m)
Exam
Can you get above it? Is it separate? Is it cystic? Roll testes between h)
two fingers and thumb.
What are causes of a dull ache?
o Infection
o Trauma (can also cause haematocele)
o Tumour (although cancers are not usually painful)
What are causes of severe pain? (2)
o Referred pain
o Testicular torsion (until proven otherwise)
What features should be noted about any lump or swelling? (SPACE SPIT)
o Size o Shape & surface
o Position o Pulsations, thrills or bruits
o Attachment o Inflammation
o Consistency o Trans illumination
o Edge
Give 7 differentials for testicular swelling
 o Tumour
o Epididymitis
o Orchitis
o Hydrocoele
o Spermatocoele
o Varicocele
o Indirect inguinal hernia

Testicular cancer
Most common tumour in men in their 3rd and 4th decades and curative treatment is now available for most of them
Undescended testes are 30% more likely to become malignant

What are the two types of primary testicular tumours?

o Germ cell tumours (90%) Fast growing and aggressive. Metastasise to abdominal lymph and lungs
o Stromal tumours from supportive tissues
What are the three types of secondary tumours, which might be found in the testes? Lymph!
o Lymphoma
o Chronic lymphocytic leukaemia
o Acute lymphoblastic leukaemia (children)
What is the typical presentation of testicular cancer? (2)
o A painless progressively enlarging testicular lump +/- secondary hydrocele
o May also be nodular

Testicular torsion
This is a surgical emergency! Can cause infarction and even death. Most occur in young boys but can occur at any
age.
Describe the typical presentation of testicular torsion (6)
o Scrotal pain, radiates to the abdomen
o Sudden onset,
o Not typically relived by analgesics
o Associated with nausea, vomiting, urinary frequency and low grade fever
o Exacerbated or initiated by intercourse or vigorous activity
o 50% have had prior episodes that resolve spontaneously
o Pain eases to some degree after event!??
Give 4 features on examination
o Red, oedematous, enlarged and extremely painful
o Elevation and horizontal lye of the testicles
o Loss of cremasteric reflex
o No relief with elevation
What is the cremasteric reflex?
o A superficial reflex which utilizes sensory and motor functions of L1-L2. Involves contraction of cremasteric
muscle and elevation of testes when the medial part of the inner thigh is stroked.
How would you differentiate between epididymitis and testicular torsion?
o Testicular torsion is NOT relived by elevation, unlike epididymitis
What investigations might be used in testicular torsion? (3)
o FBC may show WCC
o Urinalysis?
o Ultrasound Doppler to show testicular blood flow and rule out differentials
What is the treatment? (2)
o Urology consult ASAP! Surgery needed to correct
o Analgesic
 What are the complications? (1)
o Infarction and necrosis of testicle

Epididymitis
Can occur at any age. In younger men, it is most often due to STI and in older men; it is usually due to bacteria.
However, there is overlap and a thorough sexual history is important for all groups.
What pathogens might be associated with epididymitis? (3)
o Viral mumps
o Bacterial gonococci (STI) and coliforms (e.g. E.coli)
What are the symptoms?
o Painful, enlarged epididymis
o Usually unilateral
o Fever, dysuria, increased frequency (signs of UTI)
o Similar to testicular torsion
o Mumps headache, fever, parotid swelling.
On examination? (5)
o Relief on elevation
o Pain on the posterior and superior poles of testicles
o Tenderness on palpation
o Palpable swelling of epididymis
o m/b urethral discharge or secondary Hydrocoele
What tests may be carried out? (5)
o Urethral smear
o Swab for N.gonorrhoea
o MSU
o HIV testing
o Doppler to rule out torsion
What other tests might be indicated? (3)
o STI screen
o Investigation of urinary tract
o TB infection screen
Give 4 antibiotics commonly used to treat. Carry out urinalysis!!!
o Ceftriaxone
o Ciprofloxacin
o Doxycycline
o Ofloxacin
What are some other management steps? (5)
o Rule out differentials, e.g. Testicular torsion, UTI
o NSAIDs
o bed rest
o testicular support
o abstain from intercourse until treatment complete and STI ruled out.

Orchitis
Inflammation of the testicles. They will be enlarged and tender.
What is the most common pathogen in orchitis?
o Mumps, 20% prepubertal males will develop
Name three other viral pathogens which can cause orchitis
o Varicella
o Echovirus
o Glandular fever
Give 4 bacterial pathogens which can cause orchitis (these are much rarer)
 o Syphilis
o Chlamydia
o GC??
o TB
What are the risk factors for epididymo-orchitis?
o PMH previous gonorrhoea infection, structural or functional abnormalities in urethra
o SH homosexual activity, strenuous activity when there is no opportunity to void bladder
Give the features of orchitis on examination
o Unilateral, enlarged, tender testes
o Induration (hardeninig) of testes
o Erythematous scrotum
o Enlarged epididymis
What are some of the associated symptoms?
o Fatigue, malaise, myalgia, decreased appetite
o Fever, chills, nausea and vomiting
What is the treatment?
o Antibiotics, ice, bed rest and support
o NSAIDs
o Cefalexin, ciprofloxacin

Spermatocoele
Most common cystic condition of the testes. Cyst of a tubule of the epididymis. Cysts may occur within the body of
the testes but these are much harder to palpate. Cysts are generally benign but dont hesitate to send of for further
investigations
Where are they most commonly located
o At the superior pole of the testes at the back
How do they present?
o Smooth, painless cylindrical mass. Mm to Cm in size.
o Soft and compressible
What is treatment?
o Non required, only reassurance
o Can consult urologist if concerned

Varicocele
Varicose veins of the spermatic cord.
Where do these form?
o Within the pampiniform plexus
Describe their character on palpitation
o A soft irregular mass, separate from the testes (bag of worms)
o Generally painless but there may be a dull ache or sensation of heaviness
o May collapse with elevation of the scrotum
What are some of the complications of this condition?
o May become indurated or thrombosed
o Associated with infertility
o Recurrence
How is it treated?
o Trans-scrotal vein ligation
o Self-care not standing for long periods of time, rest, etc.

Hydrocoele
Collection of straw-coloured fluid between the two layers of the tunica vaginalis.
What are the two forms?
 o Communicating open to peritoneum
o Non communicating - not open to peritoneum
Describe features on examination
o Soft, fluctuant and transilluminable
o Typically, at the front of the scrotum, but can extend to the back
o Non tender but may be sensation of heaviness (can be very big)
Give 3 potential causes
o Trauma
o Infection
o Tumour (Could be something sinister so follow up)
Management?
o Confirm with ultrasound scan
o Aspiration
o Otherwise reassurance and follow up to monitor for something more sinister.
What is the common complication?
o Recurrence
 Prostate diseases

Prostatitis
Typically, an acute presentation. If someone is presenting with chronic symptoms this si more sisnister for prostate
cancer.
Give three pathogens which can cause prostitis
o Gram negative E. coli, pseudomonas
o Gram positive Enterococcus
o STI Chlamydia
Give two routes of infection
o Ascending
o Reflux?
Describe the presentation
o Significant pain in the peritoneum (siting on a stick) can radiate to back
o Low grade fever
o Pain on ejaculation
o Painfull, tender, swollen, boggy, indurated prostate on PR
o Haematospermia,
Management?
o Urinalysis haematuria, leucocytes, bacteriuria, pyuria (pus)
o Urine MSC
o FBC leucocytosis
Treatment?
o 4-6 weeks antibiotics. Levofloxacin, ciprofloxacin
o Analgesics
o Siltz bath
o Follow up cultures to make sure it is cleared
Give 4 pathogens that can cause chronic prostatitis
o E.coli
o Proteus
o Klebsiella
o Enterococcus
How does management differ from acute?
o Need to be referred on if recurrent
How is non-bacterial prostatitis treated?
NSAIDs
Alpha-blockers (muscle relaxants)

Benign prostatic hyperplasia

Incidence increases with age as does the range of PSA needed to diagnose. Caused by proliferation of the inner zone
of the prostate rather than the outer zone as seen in prostate Ca
What percent of males over 64 are effected by BPH?
o 40%
Give 7 symptoms
o Reduced, weak urinary stream
o Double micturition
o Hesitancy
o Terminal dribbling
o Straining to void
o Feeling of incomplete voiding
o Symptoms of UTI (if irritated) dysuria, nocturia, urgency, etc.
Describe the investigations for BPH
 o U&E
o US post micturition residue??
o Voiding flow rate
o PR exam
What can cause raised PSA?
o Prostate exam
o UTI or other infection
o BPH
o Prostate cancer
o Direct trauma (anal intercourse, etc)
o jaculation
Treatment if the patient is not troubled by symptoms?
o Watchful waiting
o Decrease evening fluid, alcohol, caffeine
o Prevent constipation
Treatment with mild to moderate symptoms?
o -adrenoreceptor agonists doxazosin (prevent neural stimulation of smooth muscle contration)
o 5--reductase inhibitors finasteride (prevent conversion of testosterone to dihydrotestosterone)
Give the SE for doxazosin
o Hypotension, dizziness, drowsiness
Give the SEs for finasteride
o Impotence, decreased libido
When should patients be referred
o Red flags for cancer (passage of blood, referred back pain, weight loss, etc)
o Complicated BPH
o Acute retention
o Nodular/firm prostate on PR
o Increased PSA
o Failure to respond to drug therapy
Give the ranged of PSA
o >60 = >3.0 ng/ml
o >70 = 4.0 ng/ml
o Over 70 = >5.0 ng/ml

Prostate cancer
Craggy, hard prostate with raised PSA = 2-week wait
What should be done for all patients with prostate symptoms?
o Check for infection
o Check obs
o PR exam
o PSA